GPs in the driving seat for ‘clinical commissioning’
pharmafile | August 12, 2010 | Feature | | GP, NHS, PCT, government
The reforms of the NHS unveiled in July will have a radial impact on how the service is run, giving GPs control of spending and seeing current management structures abolished.
Many commentators say the reforms are as great as any the health service has undergone since its creation in 1948, but opinions are divided on whether the plan to improve patient care and cutting costs can work.
England’s 152 Primary care trusts (PCTs) currently manage around 80% of the £105 billion NHS budget, but these will all be abolished by 2013 under the new plans, as will the 10 regional Strategic Health Authorities.
The plans are set out in the White Paper, Equity and Excellence: Liberating the NHS released 12 July by the coalition government.
Under the proposals, primary care doctors will be obliged to come together in consortia to take charge of the NHS budget for mental health, hospital and community services. These groups will start taking duties from 2012 and GPs will have full financial responsibility from April 2013.
This will be balanced with the creation of an independent NHS commissioning board that will allocate and account for NHS resources. The board will calculate practice-level budgets and allocate these directly to GP consortia, as well as holding practices to account.
Giving greater power to GPs had been championed by Andrew Lansley before the election in May. Unveiling the new White Paper he said the reforms would “empower” doctors and tackle the frustrating bureaucracy that “plagued the health service”.
Lansley added: “We have got to design services better and save money. GPs are best placed to do this.”
A similar system, the general practitioner fund-holding scheme, was introduced as part of the Major government’s 1991 NHS reforms but was swiftly abolished after Labour came to power in 1997.
Even before this ‘fund-holding’ had faltered because too few doctors were involved – under Lansley’s new policy GPs will not be able to opt out of the system.
Reaction
TheNHS Alliance has welcomed the new proposals and its chairman Dr Michael Dixon said they offered a “unique opportunity for frontline GPs and the managers and other clinicians who work with them to make a real difference to the health of their patients, the services they receive and make the best out of limited resources.”
Dixon added: “The NHS Alliance will be leading from the front, supporting and enabling frontline GPs and practices to make it happen.”
Dr Amit Bhargava, clinical lead of the Clinical Commissioning Federation, said: “Clinicians – who spend 80% of the health resource, who have great influence on flows of patients, have organisation memory and have the intellectual capacity and capability – are in exactly the right place now to deliver the paradigm shift that will improve the well-being of the health service that is so critically needed.”
BMA chairman Dr Hamish Meldrum said doctors were ideally placed to help determine the health needs of their local population.
“Every time they see a patient they have to make decisions about their care, in partnership with them. Doctors, and their staff, already take the lead on designing services and innovating new treatments for patients and will be interested in discussing how these roles will be enhanced.”
But he added: “Any reorganisation of the NHS must take place in consultation with clinicians so that it does not cause any disruption to patient services or needlessly waste the valuable time of healthcare professionals.”
Mixed reactions
Other organisations went further in expressing their reservations about the plans, with think tank Civitas saying there was little evidence it would be better than the current system and even warned that restructuring could “set the NHS back by three years”.
Nigel Edwards, the acting chief executive of the NHS Confederation, said the proposed changes would create “a market dynamic”.
Speaking before the Paper’s publication he told the BBC Radio 4 Today programme: “I think this is quite a major shift because the end product of these reforms will probably end up looking like the gas and telecom market rather than the NHS we have been used to in the sense big organisations making big contracts.”
Critics also point out that GPs have been taught to diagnose and to cure, not to allocate limited budgets and that this should be left to professional financial managers.
Some are also concerned that patient care may be adversely affected if primary care doctors are forced to spend too much time ‘balancing the books’ instead of spending it with their patients.
PCTs ARE DEAD: LONG LIVE PCTs
The plans will see primary care trusts and strategic health authorities abolished by 2013, but no one working in the NHS believes GPs can fill the managerial vacuum without help.
The government has refused to detail just how many PCT managers should remain in the system, but up to 60% of staff are expected to remain, simply working for GP consortia instead.
The NHS Alliance, which represents primary care professionals, says PCTs will still have an “invaluable contribution to make in the move to clinical commissioning”.
“We should not throw the baby out with the bath water,” said Michael Sobanja, chief executive of the NHS Alliance.
“PCTs have the skills and expertise which will be absolutely instrumental in implementing the coalition’s plans for clinical commissioning successfully.
They have been unfairly criticised by the government, who has so far failed to see that PCT managers and staff will need to be supported during this time.
“In a transition period such as the one the NHS is going through at the moment, views can become polarised, with some people keen to get rid of the old regardless while others are equally keen to prove that the new ideas are unworkable.
Sobanja added: “But the reality is not as black and white as this, and we need everyone on board to make clinical commissioning work. PCT staff must not be forgotten. Patient care must not be forgotten. We need to work together and not let the uncertainties blind our judgement.”
The Alliance has broadly come out in favour of the plans but has said it “recognises that there is still a lot of work to be done” before the plans can be implemented effectively.
Dr David Jenner, general medical services lead for the NHS, added: “It is vital that we look after those with the commissioning skills who are facing an uncertain future. We should respect their needs and look quickly to ensure their skills and organisational memory can be smoothly aligned with clinicians in the new consortia.”
Uncertainty among GPs
A recent survey by medical networking site Doctors.net.uk showed that out of 81 doctors surveyed, 82% responded that they were not ready to take the fiscal responsibility set out in the coalition’s White Paper. The site’s medical adviser, Dr James Quekett, said: “Naturally there is a lot of excitement about the White Paper but also much uncertainty about the new plans for GP commissioning.
“With allocation of time, resource and funding still to be resolved, GPs are expressing concern about how the reform will work in practice, and are pointing out that for this to work all doctors need to be engaged and involved – not just GPs.”
There is concern that PCT managers will simply filter down into the newly formed consortia and take over the day-to-day book-keeping.
Mark Britnell, partner and head of the UK and Europe health division of management consultants KPMG and a former leading NHS reformer said at a commissioning conference in July that consortia should not consider mimicking existing PCTs. He warned: “500 ‘mini-me’s’ trying to commission would be a disaster.”
If former PCT managers are to be called in to help lead GP consortia during the transitional period and beyond, this would effectively moderate the ostensible overhaul of the NHS structure and simply shift power around until it settles back onto the shoulders of the former PCT managers.
Q&A: GP consortia
Q: When will GP consortia begin work?
Shadow consortia are set to begin work in 2011 and then assume full control in April 2013.
Q: What will the GP consortia do?
Currently, primary care trusts (PCTs) are in charge of around 80% of the total £105 billion NHS budget. The new White Paper proposes to shift this control from PCT managers to collective groups of GPs who will consult with a newly created NHS Board and local authorities on where the money should be spent.
Q: Is the coalition government really doing away with PCT managers altogether?
It is recognised that some top managers from PCTs could simply merge into the newly established consortia and become the de facto leaders in areas where GPs are not confident enough to take on financial responsibility.
Q: How will this affect pharma?
The decision making process will change. GPs were sidelined by PCTs on the big decisions in recent years, but they will now be (in principle) the legal guardians and key decision-makers on around £80 billion of the NHS budget.
Q: What is the potential of the reforms?
The changes could cut through the bureaucracy of PCTs, which many say have been too slow in reforming services around patients. Health secretary Andrew Lansley says patients should be fully involved in their care, and has used the maxim ‘no decision about me, without me’ to sum this up.
Q: What are the risks of the reforms?
The cull of nearly half of all NHS managers will remove their financial and organisational structures, potentially creating a large knowledge gap. It could also cause major disruption, and the reforms could be pushed through too quickly for GPs to adapt to their new responsibilities.
Q: Has anything like this been tried before?
A similar system, GP fund-holding scheme, was introduced by the last Conservative government in 1991, then abolished by Labour in 1998. One key difference is that fundholding was a voluntary scheme, whereas this is mandatory.
Q: How will this affect hospitals?
All NHS acute trusts will be given the chance to take on Foundation status. A current limit on how many private patients acute trusts can take on will also be lifted. The health secretary says these new Foundation trusts will create a “vibrant industry of social enterprises” to help hospitals to make money as well as spend it.
Q: How does this affect NHS finances?
Incremental ‘real terms’ growth will be maintained, but the NHS must still find around £15 – £20 billion worth of savings through increased productivity by 2015.
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